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Home My WebLink About6126-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy Date .......... l~e.. ~0 ......... , 19.~. THIS CERTIFIES that the building located at . .. ~t,l,ll~t~l'. &WO ........ Street Map No.M ,8,11~... Block No ........... Lot No... ~ .... 0~lt, OhO~ .. ][ ,~,. · · conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... l~b~.. ~ ~.., t4~pursuant to which Building Permit No.~[~ dated ......... IMI~O..., ~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is . .l~.va'ce. ~. fa~ly, d~lltn~ ...................................... The certificate is issued to ...~].l;I.~la. [[~ .~th ....... .(~F. ..................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. [,~1, ............................. UNDERWRITERS CERTIFICATE No .... 11..~ ...................................... HOUSE NUMBER...]0~0 ..... Street .....~t~l.~,'t~'&~ .~.~O ............................ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6126 Z Date ......................... Jl~J~w-.-.:.~ ......... 19..~.. Permission is hereby granted to: ..k'.t3JJ. an..~...~.t~ ....................................... to ~.11~1,~...l~u ..~dJ. f,.ton., o~.. ax~a t,,tn~..d~e 13..~ul ................................................................. at premises located at .~.~....Jjj,I~W&~;ij,..~i ............................................................................. pursuant to application dated .................. ~tb~tr ...... '~8 ............... , 19~j...., and approved by the Building Inspector. Fee Si..~.e.i~J~. ............ Building Ihsp~etbF -~ FOU. M NO. S TOWN OF SO~TNOLD Building Deparlment Town Clerks Office Southold, N. ¥. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage dispcsal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, N[ultiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect or Engineer responsible for the building. .5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or tppogrophic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare o certificate. C. Fees: 1. Certificate of occupancy $§.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 Date ....~..ec.e~]2e~.....20...19.2~.. New Building ....A...d..d..~..~..°.nOId or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .... .~...~.~.a.~.f~,T...~.¥..~ ............................................................................................... Owner Or Owners Of Property ..... 1/IT,~,~,~P,~II....~..~....~.~..~,~ ........................................................................... Subdivision ~' IVIoS o["[~rtd Lot No..~..6.../.?.....8Block No ............. House No.....,~.Q.~.O Permit No..~.~.~6~ ....... Date Of Permit ~&p...1.a...~.~Rpplicant ..... ~3a...SSd.:~:t ......................................... Health Dept. Approval ..... .~...*..~...'. ............................. Labor Dept. Approval N.R. Underwriters Approval .~....~..6.~.~7.c). ............................. Planning Board Approval ........ ..~..'...~..'. ...................... Request For Temporary Certificate ........................................ Final Certificate Fee Submitted $ ...~'..?..0..0.. ....................... / ~ Sworn to before me this ....... ~..0..... day of ............. .D..e...o....1.~7..2. ............ (stamp or seal) Notary Public .................................... County lrORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office Southold, N. ¥. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topogmphic features. 2. Final approval of Health Dept. of water supply and sewerage dispcsal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $I.00 New Building ~.,,,~,,.(,.,,~,.... Old or Pre~-existing Building ............................ Vacant Land Subdivision .......... .~; ....................... Lot No ............. Block No ............. House No:...~.. Permit No ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ........ ..~..:....~.... ....................... Labor Dept. Approval ............. ! ............................... Underwriters Approval .....~.......~....?...~....~.. .................. Planning Board Approval ...~...i...~... .......................... Request For Temporary Certificate ........................................ Final Certificate .....~ ................... Fee Submitted $ ...... ~ ......................... Construction on above described building and permit meets all applicable codes and regulations. Applicant ......................................................................................................... Sworn to before me this ........ day of .................... ......... .?. ........... (stamp or seal) Notary Public .................................... County FOBM NO, I TOWN OF soUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD~N. Y. pp oved ........................................ , 19 ........ Permit No. c) Disapproved. ~/c ................................................ ~ Application No. (~ / )~ ~' APPLICATION FOR BUILDING FE~4~I~ Dote ............. , 197~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Plot p/an showing IocatJ~,of lot and of buildings on premises relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drown on the diagram which is part of this application. c. The work covered by this application may not be commenced bsfore issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the progress of the work. e. No building shall be occupied or used in whole or in port for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS H.EREBY MADE to the Building Department* for th~iss~ance of a .Building Permit pursuant to,the Building Zone Ordinance of the Town of Southold, Suffolk County,~b,l~f Yo.k, and othe, applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or altering, or for removal or demolition, as herein described. The opp,icant agrees to comply with all applica~~ _ ~ ~ name, if a c~%ration) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. If applicant is a. corporate, s!gnature of duly authorized officer. (Name and title 'of corporate officer) 1. L(x:ation of land on~ w~ch _l~,~pc~ed,o(k will be done Map ~ ............... ~ ................... Lot No.'. ..... ,.,~,...7~...~..J~. ..... ~ ....... ~ 0 'Municipality ........ r,,3 ....................... 2. State existing use aid occupancy of p~nd occupancy of proposed construction: a. Existing use and occupancy ........ · ................ ;..; ...................... ~ ............... ............................................................. b. Intended use and occupan;;, ....~ ........................................................................ 3 ,-Nature of work (check whici~ aDplicoble): New Building .................. Addition .................. Alteration .................. Repair .................. _.~emoYa! .................. ~l~'emoli.t~n .................. Other Work (Describe) ........................................ ,. Est, ot d Cost Cee ............ (to be paid on fi!lng this application) 5. If dwelling, number of dwelling umts ........ ~....Number of dwelling units on each floor ..... ~ ................. If garage, number of cars .............. 6. If business, commercial or mixed occupancy, ~l~e~Jfy~atu~ and extent of ach t,zDe of use ....... ...'~.....~ ........... ~. D,~ens~o.~ ~f ~:,st~,g/~t..~s,_'~ o.y: ~,o.t...~.~ Rear ...~.~ ...... Depth ~.¢..~ Height ..~..~. .......... ..~/~/mu~'~r e~ Stori,s ...~ .............................................. ' ........ p I~..~....i...[~ ........ ..~ght .~ ..Number of Stories 8. Dimtnsion~ of~emir,~new construction' Front t~ Rear "~1"1~' · /Z ~ · ~ . ~i~.~ ........................................ C;~ .......... ~ ............... ~ ...... Height L~.~. Number of Stories ...... ~.~.~ .......... · ............................................................ ~ ...................... Size of lot: Fremont ....~..~.~..~..~1..~ ..... Rear .......... .~...~'...~.¢.~...~. ........ Depth ../..~/....~.. I. 0f Purchase .~...../...~..Z...~-... ................ Name of Former Owner ~...../.~.. Date Zone Or usc district"i~hich premises are situated ..................................................................................................... 10. 11. 12. 13. Does proposed construct;o~iol6te any zoning law, ordinance Name of Owr'er of p~~dress ..~.....~...~..f/.!~..~p~h~ne NZ.~. Arch tect .............. Name of No .................... o, Co.,oc, ............ .................................................... PLOT DIAG~&M L~ate clearly end distinctly oll buildings, whether existing or proposed, and indicate all set-~ck dimensions from prope~, lines. Give street ~nd b~ock number or description according to deed, and show street nam~ and indicote whether ;nterior or corner Jot. /¢~,// COUNTY ~.;....~ .... ................................................................................................ being duly sworn, deposes and soys that he is the appjicant (Name of individual signing application) above named. He is the ................................................................................................. (~ontractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perfor~n or have ~formed the said work and to ~ke and file this application; that alt statements contained in this application~ true to the best of h s knowled e and bel ef and k '~ · · g ; ~ ,a{ the work wl,I be performed~n the manner set forth m the 9~l~tion f ed therewith ~ ~oto~/~ui~~.~:..~~o~ .............................. i~i~'~'~;U;;';¢"~ii~;~ ............................. Comrn,~ion fixFro' ~ ~ ~' ~ ,t~ ~,,~rc~ 80, ~/~